NCC242381_FRO Submitted_20240805

CARY
— NORTH CAROLINA
Stormwater Division
FINANCIAL RESPONSIBILITY -OWNERSHIP FORM
No person may initiate any land-disturbing activity covered by Cary's Sedimentation and Erosion Control
Ordinance before completing and filing this form with the Cary Stormwater Division. Indicate N/A if a
question is not applicable.
Section 1
PROJECT NAME: Rose Park Manor
PROJECT DEVELOPMENT PLAN #: 24-DP-6920
PROJECT LOCATION:
076310368033
Property Tax ID#/PIN
498 Kilmayne Dr.
Street Address
APPROXIMATE DATE OF PROJECT INITIATION: 8 July 2024
ACREAGE OF LAND TO BE DISTURBED: 3.08
APPLICANT SUBMITTING PLAN: (must match the financially responsible party named in Section 2
of the Financial Responsibility/Ownership (FR/O) Form.)
Patrick Theismann
Name(Person or Firm)
Section 2
PERSON(S) OR FIRM(S) FINANCIALLY RESPONSIBLE FOR THIS LAND-DISTURBING ACTIVITY:
(If out of state, a registered agent in North Carolina must be used.)
Beacon Management Corporation - Patrick Theismann
Name(Person or Firm)
408 Battleground Avenue
Street Address(No PO Box)
Greensboro, NC 27401
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carvnc.ciov
updated: 04/2023

[phone]
Telephone Number
N/A
Fax Number
[e-mail]
E-Mail Address
REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:
(If out of state, a registered agent in North Carolina must be used.)
George Carr III.
Name
408 Battleground Avenue
Street Address(No PO Box)
Greensboro, NC 27401
City State Zip
[phone]
Telephone Number
N/A
Fax Number
[e-mail]
E-Mail Address
The Town reserves the right to contact either the financially responsible person or registered agent listed
below in case of violation. Please indicate your preference below.
Patrick Theismann OR George Carr III
Financially Responsible Person Registered Agent
Section 3
LANDOWNER OF RECORD:
Ledson Properties of the Southeast
Name(Person or Firm)
076310368033
Property TaxID#/PIN
775 Weathergreen Drive
Street Address(No PO Box)
Raleigh, NC 27615-3224
City State Zip
Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 2 of 3 updated:04/2023

STATEMENT OF LANDOWNER CONSENT:
In accordance with NCGS 113A-54.1(a), I hereby declare that I am the owner or legally authorized
representative of the owner of the property described above and provide my consent for the applicant
cited in Section 1 above to submit an erosion control plan to the Town of Cary Stormwater Division and to
conduct the planned land-disturbing activities on the property listed in Section 1 above.
D ug Ledson President
Na Title or Authority
Gt'\-'1I 06/10/2024
Signature Date
landdev pingAgmaii.com [phone]
Email Telephone Number
THE ABOVE INFORMATION is true and correct to the best of my knowledge and belief and as provided
by me while under oath. (This form must be signed by the financially responsible person, if an
individual or by an officer, director, partner, attorney-in-fact, or other person with authority to
execute instruments for the financially responsible person if not an individual.)
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'State of North Carolina, hereby certifies that A/kw( Tht,J/na/7r1
personally appeared before me this day and under oath acknowledged that the above form was
executed by him/her.Witness my hand and notarial seal,this / day of Jk , �J Q
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Cary
316 North Academy Street, Cary, NC 27513 PO Box 8005, Cary, NC 27512-8005
Tel: 311 or 919-469-4000 outside Cary limits www.carync.gov
Page 3 of 3 updated:04/2023